Aetna-CVS Merger Hearing

Aetna-CVS Merger Hearing

JUNE 19, 2018

CALIFORNIA DEPARTMENT OF INSURANCE

1

Dave Jones Insurance Commissioner

opening remarks JUNE 19, 2018


2

Kristen Miranda, Aetna Paul Wingle, Aetna

Thomas M. Moriarty, CVS Health Elizabeth Ferguson, CVS Health

JUNE 19, 2018


3

Thomas L. Greaney, J.D. University of California Hastings

College of Law JUNE 19, 2018


4

Richard Scheffler, Ph.D. University of California, Berkeley

School of Public Health and Goldman School of Public Policy

JUNE 19, 2018


5

Testimony Regarding CVS Health Corporation’s Proposed Acquisition of

Aetna Inc.

Richard M. Scheffler Distinguished Professor of Health Economics and Public Policy

Director, Nicholas C. Petris Center on Health Care Markets and Consumer Welfare (http://petris.org/ )

School of Public Health and Goldman School of Public Policy

University of California, Berkeley

[email protected]

6

http://petris.org/

mailto:[email protected]

1. Average Monthly Premium for PDPs, 2006-2018

--<.I). -

50

45

E 40 ::::I

E 35 OJ L.. a.. > 30

..c +..I

§ 25 ~

20

15

-- --

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Year

- - United States --California

Source: Kaiser Family Foundation analysis of Medicare plan enrollment and premium data files. Notes: PDP=stand-alone prescription drug plan. 7

2. PDP Regions

MI

WY

, .• _ ., •

PDPRegions

ND

SD

NE

co

Note: Each territory is its own PDP region.

Source: Centers for Medicare & Medicaid Services (CMS). '1>DP Regions.,, Available from: https:/ /www.ems.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovGenln/downloads/PDPRegions. pdf 8

1. Level of Concern and Scrutiny Based on HHI Change and Resulting HHI Level

IIllILevel < 1,500 1,500 to 2,500 >2,500

IIllI Change <100 Low Low Low 100 to 200 Low Moderate Moderate >200 Low Moderate High

Low: "Unlikely to have adverse competitive effects and ordinarily require no further analysis" Moderate: "Potentially raise significant competitive concerns and often warrant scrutiny" High: "Presumed to be likely to enhance market power"

Source: Author's analysis of U.S. Department of Justice and Federal Trade Commission's 2010 Horizontal Merger Guidelines (pg. 19). Note: HHI=Herfindahl-Hirschman Index.

9

2. U.S. PDP Enrollment and Market Shares, 2018

Parent Organization Enrollment Market Sha re

CVS Health Corporation 6,029,689 24.1%

UnitedHealth Group, Inc. 5,311,049 21.3%

Humana Inc. 4,876,657 19.5%

Express Scripts Holding Company 2,440,926 9.8%

Aetna Inc. 2,130,380 8.5%

WellCare Health Plans, Inc. 1,063,742 4.3%

CIGNA 765,870 3.1%

Rite Aid Corporation 513,664 2.1%

Health Care Service Corporation 349,325 1.4%

BCBS MN, MT, NE, ND, WY, Wellmark IA and SD 277,860 1.1%

Anthem Inc. 274,094 1.1%

TOTAL* 24,033,256 96.3%

Source: Author's analysis of April 2018 enrollment data published by CMS (https://www.cms.gov/ResearchStatistics-Data-and-Systems/S tatistics-Trends-and-Reports/MCRAdvPartDEnrolData/Monthly-Enrollment-byContract-Plan-State-County.html ) Not~: PDP=stand-aloneprescription drug plan. *Only includes parent organizations with greater than I percent market share.

10

3. California PDP Enrollment and Market Shares, 2018

Parent Organization Enrollment Market Share

UnitedHealth Group1 Inc. 6291798 27.8%

CVS Health Corporation 5681888 25.1%

Humana Inc. 4841290 21.4%

Aetna Inc. 195,096 8.6%

Anthem Inc. 1261121 5.6%

WellCare Health Plans1 Inc. 941478 4.2%

Express Scripts Holding Company 821600 3.7%

California Physicians' Service 471142 2.1%

TOTAL* 212281413 98.5%

Source: Author's analysis of April 2018 enrollment data publishoo by CMS (https://www.cms.gov/ResearchStatistics-Data-and-Systems/Statistics-Trends-and-Reports/MCRAdvPartDEnrolData/Monthly-Enrollment-byContract-Plan-S tate-County. html ) Notes: PDP=stand-alone prescription drug plan. *Only includes parent organizations with greater than 1 percent market share.

11

3. Average PartD Region-Level PDP Market Concentration (Weighted by PDP Enrollment), 2009-2018.

• 2,500

2,250

2,000

~~~~~~~~~~~~~~~~~~~~~~~ +434 HHI :A.

~ 1,750

1,500

1,250

1,000

- -- - - -

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Year

United States

--California

.._ United States if CVS/ Aetna merged

♦ California if CVS/ Aetna merged

Source: Author's analysis of April 2018 enrollment data published by CMS (https://www.cms.gov/ResearchStatistics-Data-and-Systems/Statistics-Trends-and-Reports/MCRAdvPartDEnrolData/Monthly-Enrollment-by-Contract-Plan-State-County .html ) Notes: PDP=stand-aloneprescription drug plan. HIIl=Herfmdahl-Hirschman Index. The HIIls shown in the figure are a weighted-average of the HHis of Medicare Part D's 34 regions (weighted by PDP enrollment).

+410 HHI

12

4. PDP Market Concentration, 2018 (by PDP Region) 2018

PDP Post-Region Merger # States 2018 HHI HHI

33 Hawaii 4,898 6,263 19 Arkansas 1,984 2,844

10 Georgia 1,977 2,772 20 M issis.sippi 2,006 2,722 18 Missouri 2,015 2,645 24 Kansas 2,045 2,669 8 North Carolina 1,700 2,249

22 Texas 1,769 2,299 23 Oklahoma 1,996 2,468 15 Kentucky, Indiana 1,647 2,107 21 I.Duisiana 1,717 2,175 9 South Carolina 1,687 2,144

5 District of Columbia, Delaware, Maryland 1,797 2,250 32 California 2,007 2,441 3 New York 1,844 2,273 14 Ohio 1,755 2,181 2 Connecticut, Massachusetts, Rhode Island, Vermont 1,610 2,029

7 Virginia 1,606 2,004 6 Pennsylvania, West Virginia 1,702 2,095 12 Alabama, Tennes.see 1,602 1,986 26 New Mexico 1,717 2,087 16 Wisronsin 1,588 1,947 11 Florida 2,292 2,628 27 Colorado 2,256 2,582 25 Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota, Wyoming 2,145 2,466 17 Illinois 1,547 1,839

28 Arizona 1,866 2,149 29 Nevada 2,383 2,638 4 New Jersey 2,320 2,551 31 Idaho, Utah 1,836 2,053 30 Oregon, Washington 1,614 1,814

13 Michigan 1,795 1,957 1 Maine, New Hampshire 1,546 1,691 34 Alaska 2,715 2,740

AVERAGE (weighted by PDP enrolment) 1,861 2,271

Source: Author's analysis of April 2018 emollmmt data published by CMS (https://www_cms_gov/Res~ Statistics-Data-and-Systems/Statistics-Trends-and-Rgxrts/MCRAdvPartDEnroIDatalMonthly-Enrollmmt-byContract-Plan-State-Connty_html ) Notes: PDP= stand-alonepresaiption drug plan_ IIlil=Hedindahl-Hirachman Index_ 2018 IIlil treats CVS and Atma as separate finns_ 2018 Post-Mager IIlil assumes CVS and Aetna are a single finn in IIlil calwlations_

13

Neeraj Sood, Ph.D. University of Southern CaliforniaSol Price School of Public Policy

JUNE 19, 2018


14

Potential effects of the proposed CVS acquisition of Aetna on competition and consumer welfare

Neeraj Sood, PhD June 19, 2018

15

Disclosures

1. Support for the research cited in this presentation and for my appearance at this hearing was provided by the American Medical Association.

2. This presentation reflects my views and opinions, not necessarily the views of the American Medical Association or of my employer, the University of Southern California.

16

About me

• Professor of Health Policy at the Sol Price School of Public Policy and Schaeffer Center, University of Southern California (USC)

• Research focused on health insurance markets, pharmaceutical markets and global health

• Published more than 100 papers and reports • Associate editor of Journal of Health Economics and Health Services

Research • My work on health care costs and the pharmaceutical supply chain has been

cited by the Council of Economic Advisors of President Obama and President Trump.

• Scientific advisor for several organizations in the health care industry

17

Today’s talk • Market overview: How do drugs reach from

manufacturers to consumers? • Effects on competition in the insurance market • Effects on competition in the pharmacy market • Effects on competition in the PBM market • Conclusion

Conceptual framework: Flow of prescription drugs

Manufacturer Wholesaler Pharmacy Beneficiary

Pharmacies may be mail order or retail, and may be integrated with PBM. Plan sponsors may include employers, unions, managed care orgs, among others. 19

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Conceptual framework: Flow of money

Formulary payments, market share

payments, rebates

Flow of Money

Negotiated payment

Payment

Premium

Premium

Copay/ cost

sharing Drug acquisition

cost

Wholesale price

Copay assistance

Manufacturer

Wholesaler Pharmacy

Beneficiary

Health Plan PBM

Plan Sponsor

Share of rebates from manufacturer


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manufacturer

Conceptual framework

Formulary payments, market share payments, rebates

Flow of Prescription Drugs Flow of Services Flow of Money

Negotiated payment

Payment

Premium

Premium

Copay/ cost

sharing

Copay assistance

Manufacturer

Wholesaler Pharmacy

Beneficiary

Health Plan PBM

Plan Sponsor

Share of rebates from

Preferred placement on formulary

Managed drug benefits

Rx drug coverage

Retail distribution Wholesale distribution R&D, marketing, manufacturing

Drug acquisition cost Wholesale price


How do we estimate the flow of money?

1. Identify top publicly traded firms for each market segment: manufacturers, wholesalers, retailers, pharmacy benefit managers, & health plans

2. Use SEC filings of these firms to estimate: – Gross profits: Revenue less cost of goods/services sold – Net profits: The profits returned to owners after operating expenses

3. Use the conceptual framework and financial data to illustrate the flow of funds for a drug purchased by an insured consumer at a retail pharmacy

22

$100$81$76$61

rs ap c er

Flow of $100 spent on pharmaceutical drugs, overall industry

$58

Production Insurer Costs

$19 $17

PBM $5

Pharmacy $15

Manufacturer Wholesaler $41

$2

PBMs manage claims and set u networks of pharmacies, create drug formularies and negotiateWholesalers purchase drugs from manufacturers and distribute them to pharmacies.Insu er provide prescription drug cov ge and contract with PBMs.Manufacturers conduct R&D, produce and market the drug. discounts and rebates with drug makers. Pharmacies pur hase drugs from wholesalers and dispense them to patients.

24

-

Net profits, overall industry

Net Profits $23

$8

$10

$12

$14

$16 $15

of $100 by industry

$6

$4 $3 $3 $2

$2 $0.32

$0

26

Is anyone in the supply chain making excess returns?

• Do not evaluate directly whether middle men in the pharmaceutical supply chain are making excess returns

• Market concentration is an important indicator of companies’ ability to earn excess returns, and several segments of the pharmaceutical supply chain are highly concentrated – Top 3 PBMs account for 70% of the market – Top 3 pharmacies account for 50% of the market – Top 3 wholesales account for 90% of the market – Top 3 insurers account for 50% of the market in 33 states

27

Market power in the pharmaceutical supply chain can hurt consumers

• Market power manifests itself in practices of intermediaries in the supply chain that potentially harm consumers – Price discrimination in the pharmacy market – Insurers often charge consumers more in out of pocket costs than the drug

acquisition costs of the insurer – PBMs often have “gag clauses” which prohibit the pharmacy from disclosing to

consumers that they could save money by paying cash for their prescription drugs rather than using their insurance

– PBMs often do not disclose the amount of rebates they receive from manufacturers raising questions about the extent to which they pass on rebate dollars to health plans

– PBMs might create pressure to increase drug list prices; high drug prices might offset savings from rebates for health plans and hurt consumers in high deductible health plans who pay the list price of the drug

28



Health insurance markets in the US are highly concentrated

• The FTC considers markets to be uncompetitive or highly concentrated if the HHI for a market is greater than 2,500

• According to recent data from an AMA study, the vast majority of US health insurance markets had an HHI greater than 2,500

• Data from the Kaiser Family Foundation for the individual, small group and large group market paint a similar picture of highly concentrated markets

• Aetna, the third largest health insurer is a dominant firm in the insurance market – Aetna is the number 1 or number 2 insurer in over 70 HMO markets and over 100

PPO markets

30

The merger will exacerbate the lack of competition in health insurance markets

• CVS-Aetna will control two key inputs in the health insurance market – PBM – Pharmacy

• The merger creates the incentive to use the control of these inputs to disadvantage competing health plans – Increase in prescription drugs costs and total health care costs for

health plans – Increase in premiums faced by consumers

• Reduced competition in health insurance markets

31

How can control of PBMs and pharmacies increase health care costs for competing health plans

• The PBM arm of CVS-Aetna might reduce pass through of rebate dollars

• The PBM arm of CVS-Aetna might not optimize formulary design

• The PBM arm of CVS-Aetna might slow down claims processing

• The PBM arm of CVS-Aetna might not negotiate hard with pharmacies, especially CVS-Aetna pharmacies

• The pharmacy arm of CVS-Aetna might charge higher prices to competing health plans

32

What if competing health plans want to switch to other pharmacies and PBMs

• PBM market is highly concentrated so health plans do not have many options to switch

• Several of the largest PBM competitors for CVS-Aetna, such as OptumRx, Humana Pharmacy Solutions, and Prime Therapeutics are also owned by health plans

• CVS pharmacies are the dominant pharmacies in many markets so might be difficult to exclude CVS from pharmacy network

33

CVS-Aetna PBM has strong incentives to disadvantage competing health plans even it risks losing PBM customers

• Consider a consumer whose total health care cost is $10,000 and prescription drug cost is $1,000

• Given a net profit margin of 2.3% for PBM services, if CVS-Aetna were to lose this consumer as a PBM customer it would lose roughly $23 in profits

• Given a net profit margin of 3% for insurance services, ifCVS-Aetna were to gain this consumer from a competinghealth plan it would gain roughly $323 in profits

• Therefore, 1 insurance customer is as valuable as 14 PBM customers

• CVS has 94 million PBM customers of which potentially 22 million are Aetna subscribers

34

CVS-Aetna has strong incentives to disadvantage health plans even it risks losing pharmacy customers

• Consider a consumer whose total health care cost is $10,000 and prescription drug cost is $1,000

• Given a net profit margin of 4% for pharmacy services, if CVS-Aetna were to lose this consumer as a pharmacy customer it would lose roughly $40 in profits

• Given a net profit margin of 3% for insurance services, if CVS-Aetna were to gain this consumer from a competing health plan and that customer filled prescriptions at CVS-Aetna pharmacies it would gain roughly $363 in profits

• Therefore, 1 insurance customer is as valuable as 9 pharmacy customers

35

Is lack of competition in health insurance markets good for consumers?

• An amicus brief filed by me and other leadinghealth economists related to the merger ofAnthem and Cigna summarizes the past empirical research as follows: “This body of work finds that consolidation in health insurance markets does not, on average, benefit consumers. Although,greater insurance market concentration tends to lower provider prices, there is no evidence thecost savings are passed through to consumers inthe form of lower premiums. To the contrary,premiums tend to rise with increased insurer concentration.”

36

Potential efficiencies in the health insurance market

• Post-merger CVS would have a stronger incentive to be a better PBM for Aetna

• The magnitude of savings depends on whether CVS performscore PBM functions such as formulary design and rebatenegotiations for Aetna

• Aetna’s financial statements to the SEC state that “We also perform various pharmacy benefit management services forAetna pharmacy customers consisting of: product development,Commercial formulary management, pharmacy rebatecontracting and administration, sales and account managementand precertification programs ..”

• Therefore, it seems that Aetna already performs its core PBMfunctions and thus the potential efficiencies from merging withthe PBM arm of CVS would be minimal

37

Summary of key findings for health insurance market

• In my opinion, the potential costs of the merger due to foreclosure in the insurance market outweigh the potential efficiencies in the insurance market – CVS-Aetna will control two key inputs – CVS-Aetna have a dominant position in each of these input

markets – The number of consumers who stand to lose from the

merger is much greater than the number of consumers whostand to gain from the merger

– The profits from gaining an insurance customer are much higher than the loss in profits from losing a PBM/Pharmacy customer

– The potential efficiencies are minimal

38



The merger might reduce competition in pharmacy markets

• Pharmacy markets are highly concentrated or uncompetitive – CVS and Walgreens control between 50 and 75 percent of the drugstore

market in each of the country’s 14 largest metro-areas • CVS has a dominant position in several markets

– CVS financial statement “We currently operate in 98 of the top 100 United States drugstore markets and hold the number one or number two market share in 93 of these markets”

• The health insurance arm or PBM arm of CVS-Aetna could disadvantage pharmacies competing with CVS by excludingthem from their pharmacy network or through other business practices

• This will further strengthen the already dominant position ofCVS in the pharmacy market and will exacerbate the lack ofcompetition in pharmacy markets

40

How might CVS-Aetna disadvantage competing pharmacies

• Promote CVS-Aetna pharmacies or exclude competing pharmacies in outreach/communication with CVS-Aetna insurance subscribers

• Reduce reimbursement to competing pharmacies; subsequently buy them when they are in financial distress

• Exclude competing pharmacies from CVS-Aetna pharmacy network

• Have preferred status for CVS-Aetna pharmacies

41

But CVS is already the PBM for Aetna so they might already to favoring CVS pharmacies?

• Aetna currently does not have the incentive to favor CVS pharmacies and might resist the arrangement if it hurts Aetna

• Post merger the incentive to resist reduces as Aetna will be part of CVS

• The vertical merger is more permanent than a contract and this eliminates competition that occurs when contracts need to be renewed

• The anticompetitive effects will be larger in markets where Aetna has a dominant position

42

Potential efficiencies in the pharmacy market

• CVS argues that the merger will lead to lower health care costs through integration of pharmacy and medical data

• One potential efficiency is that providing medical data to pharmacists will allow them to better counsel patients

• However, CVS-Aetna will likely not have access to electronichealth record data for the vast majority of its subscribers.True integration of pharmacy and medical data to guide medical management of patients either in doctors’ offices or pharmacies will prove difficult without access to such data

• Another efficiency is that integration of pharmacy andhealth plan data might lead to better benefit design

• But Aetna can get this data without a merger

43

Summary of key findings for pharmacy market

• In my opinion, the potential costs of the merger due to foreclosure in the pharmacy market outweigh the potential efficiencies in the pharmacy market. – Pharmacy markets are concentrated – The potential efficiencies are minimal – Aetna has a dominant position in certain insurance

markets

44



The merger might reduce competition in PBM market

• PBM markets in the US are uncompetitive or highlyconcentrated

• Currently Aetna contracts with CVS for some PBM services • The merger will make this contract more permanent • This will contract the size of PBM market by reducing Aetna as a

potential customer • Reduced market size will deter entry of new PBM • In addition, new PBMs will have to be vertically integrated with

health plans as most major incumbent PBMs will be verticallyintegrated

46



Summary of key findings

Within each of the specific markets -- insurance, pharmacy and PBM -- in which the merger is likely to have anticompetitive effects, there are no potential benefits of sufficient magnitude and certainty that would outweigh the anticompetitive effects of the merger

48

Diana Moss, Ph.D. American Antitrust Institute

JUNE 19, 2018


49

Lawton R. Burns, Ph.D. Wharton Center for Health

Management and Economics,The Wharton School

JUNE 19, 2018


50

Limits on Consumer Benefits from Proposed Merger ofAetna, Inc. into CVS Health Corporation

L A W T O N R O B E R T B U R N S , P H . D . , M B A

T E S T I M O N Y B E F O R E T H E C A L I F O R N I A D E P A R T M E N T O F I N S U R A N C E

S A N F R A N C I S C O , C A

J U N E 1 9 , 2 0 1 8

Disclosure Support for the research cited in my testimony, and for my appearance today as an expert witness, was provided by the American Medical Association (AMA)

This testimony reflects my views and opinions, and not those of the AMA or the Wharton School

My Background James Joo-Jin Kim Professor at the Wharton School

Professor of Heath Care Management

Director – Wharton Center for Health Management & Economics

Co-Director – Vagelos Program in Life Sciences & Management

Published up to 200 academic papers and six books

Teach core course at Wharton on U.S. healthcare system

Expert witness in antitrust for DOJ FTC and several State AGs

Thrust of My Testimony Other witnesses have opined on merger’s anti-competitive effects

If found to be anti-competitive, I argue that the merger fails to deliver any offsetting or compensating consumer benefits that might nevertheless justify the merger

I am often asked to testify in anti-trust cases about the possible presence of such offsetting benefits

My analysis does not support any of the supposed benefits flowing from the retail clinics operated by CVS Health

Some General Observations The proposed merger is based on the corporate strategy of vertical integration. There is no prima facie evidence for consumer welfare benefits flowing from this strategy.

Indeed, in the healthcare industry, this strategy usually leads to higher prices, higher costs, and higher utilization. Sometimes it also results in greater market power.

Based on the research evidence, one cannot assume consumer benefits will automatically flow from such a merger.

There is a disconnect between the rationales espoused by company executives and those enunciated in academic theory and research. In the past, such disconnects can portend strategic failures to deliver on promised benefits.

Specific Conclusions One must examine the specific merger benefits advanced by the parties

The specific benefits espoused by company executives areunlikely to be achieved. The numerous benefits cited lack any documentation and are contradicted by the research evidence.

Retail clinics hosted in CVS pharmacies cannot effectively serve as a healthcare hub for patients and consumers.

CVS is unlikely to leverage its retail clinics and pharmacies to “reach out into the community where most of consumer health is determined”

Retail clinics and pharmacies are unlikely to “transform” healthcare, improve quality, improve health outcomes, or reduce cost of care.

The Health Care Value Chain

Payers Providers Producers

Payers

Government

Employers

Individuals

Philanthropic Organizations

Insurers

Health Insurers/ Hospitals/Systems Managed Care

Outpatient Care

High Deductible Physicians Health Plans (HDHPs) Alternative Medicine

Nursing Homes Pharmacy Benefit Managers (PBMs) Pharmacies

Providers Distributors

Wholesalers

Distributors

Mail-order Distributors

Group Purchasing Organizations(GPOs)

Suppliers

Pharmaceuticals/ Biologics

Medical Devices & Equipment

Medical-Surgical Suppliers

Information Tech

Contracted Orgs

Consumers Regulators Public Health

Source: Lawton R. Burns, The Health Care Value Chain (2002)

Aetna and CVS Roles in the Health Care Value Chain

Payers Providers Producers

Payers

Government

Employers

Individuals

Philanthropic Organizations

Insurers

Health Insurers/ Managed Care

Aetna

High Deductible Health Plans (HDHPs)

Pharmacy Benefit Managers (PBMs)

CVS Caremark

Providers

Hospitals/Systems

Outpatient Care

Physicians

Alternative Medicine

Nursing Homes

Pharmacies CVS Pharmacy

Distributors

Wholesalers

Distributors

Mail-order Distributors

Group Purchasing Organizations(GPOs)

Suppliers

Pharmaceuticals/ Biologics

Medical Devices & Equipment

Medical-Surgical Suppliers

Information Tech

Contracted Orgs

Consumers Regulators Public Health

Source: Lawton R. Burns, The Health Care Value Chain (2002)

Supporting Arguments (1) Defensive Nature of Proposed Merger

CVS losing business to Walgreens

CVS fear of market entry by Amazon

Aetna failure to grow via proposed merger w/ Humana in 2016-17

Aetna failure to keep pace with UnitedHealthcare acquisitions of MDs

Supporting Arguments (2) Enormous Hype Surrounding Retail Clinics

Forecasted growth has not transpired

Growth stagnant for last three years (both retail clinics & pharmacies)

Not a booming industry

May supply only 1-2% of all primary care

MinuteClinic generates <1% of CVS retail pharmacy dispensing $$

Often unprofitable

Supporting Arguments (3) Major Shortcomings of Retail Clinics

Failure to serve the underserved (poor, Medicaid, rural residents)

Failure to target the chronically ill

Inability to address chronic illness

Inability to succeed in wellness and prevention

Inability to conduct medication therapy management

Failure of community health centers (US and WW)

THANK YOU FOR LISTENING

Barbara L. McAneny, M.D. President, The American Medical

Association JUNE 19, 2018


63

Long Do, J.D.Legal Counsel, The California

Medical Association JUNE 19, 2018


64

Dena Mendelson, J.D. Senior Attorney, Consumers

Union JUNE 19, 2018


65

Yasmin Peled Health Access California

JUNE 19, 2018


66

Ben Powell, J.D. Litigation Attorney, Consumer

Watchdog JUNE 19, 2018


67

Public Comment

JUNE 19, 2018


68

Closing RemarksDave Jones

Insurance Commissioner please send comments to:

mergercomments@ insurance.ca.govby Friday, June 22, 2018

JUNE 19, 2018


69

https://insurance.ca.gov

Thank you

JUNE 19, 2018


70

Aetna-CVS Merger Hearing

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